Medical team using a laptop

Standards Key to Sharing Clinical Information

A significant percentage — some estimates as high as 85% — of the information needed to care for a patient at some point crosses enterprise boundaries. IT systems that use national data standards for information exchange make it easier to maintain a complete patient story.

The Health Level Seven International (HL7) data standards organization recently published a set of recommended data standards for the information in common clinical documents, such as a patient summary, a history & physical, a progress note, and a discharge summary. This package of standards, called the HL7 Consolidated Clinical Document Architecture (C-CDA), is referenced as a possible requirement for Stage 2 Meaningful Use of EHRs.

C-CDA can be used by clinical documentation vendors, natural language processing vendors, EHR-vendors, health information exchange (HIE) vendors, and more to exchange information from clinical documents in a standard way.

Clinicians interested in exchanging information within and beyond their practice or hospital should ask their clinical system vendors if they can send and receive electronic clinical documents using the C-CDA standard.

Get Involved

There are also opportunities for caregivers to weigh in on future standards for clinical documents — contact HL7 at caregivers@HL7.org to learn more about its Caregiver membership program.

Would You Like to See C-CDA in Action?

A group of vendors will demonstrate C-CDA at the upcoming HIMSS Government HIT Conference & Exhibit in Washington DC on June 11, 2012. Featured vendors include M*Modal, Verizon, and MEDfx, which provides the HIE product for Connect Virginia.

Development of HL7 C-CDA was supported by the Health Story Project and Integrating the Healthcare Enterprise under the umbrella of the Office of the National Coordinator’s Standards & Interoperability Framework.

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